Expectations for a longer healthier lifetime are global. Research, technology, and
guidelines have increased our sense of entitlement. There are insufficient assets anywhere
to deliver enough care to meet these expectations. Prevention is the only next step.

The demand on the mental health system for treatment has also been increasing, even
faster than population builds. More staff and more resources are allocated to repairing
what psychiatry diagnoses. Somehow this mental health work load must be reduced.

There is a larger context for the work load. Today most attention is directed
downstream at treatment and rehabilitation. But rescue medicine is not enough.

We can use primary prevention to reduce the number of people upstream, the number
coming into the system and wanting services. Healthy lifestyles in healthy communities can
reduce the impact of risk factors and create local peer support.

"Efforts to improve health, to change personal habits, and to work on unhealthy
environmental and social determinants of injury and disease touch on some fundamental
questions of morality and politics: the role of government, the place of health in
individual and community life, the use of force or persuasion to change behavior, and the
vision of society that lies behind a concern for health in the first place. These
dimensions of the problem of promoting good health have not gone unremarked, but they have
not been explored with the seriousness that they deserve." (1)

A serious gaze will help in not overlooking a risk factor for psychiatric diagnoses -
abuse.

For, as Labonte reminds us, "It is at the more mundane level of how people treat each
other that civil society and a common good are created and bases established for
collective actions at higher political levels."
(2)

Most abusers, not all, but most, are men. (3)
Their mothers and wives and sisters often protect them at their own and the victim's
expense. (4)

But in the executive summary of the US Surgeon General's Report on Mental Health, there
is one mention of abuse and neglect, in the abstract fo the chapter on children. One
mention, in 30 pages of summary. Yet the American Journal of Public Health reported this
fall, "In any given year in the United States, more than 2 million wives are
physically battered by husbands and nearly 3 million children are reported as victims of
abuse." (5)

Studies consistently confirm a 50-80% prevalence rate of sexual and physical abuse
among persons who later acquire diagnoses of mental illness. (7)

So roughly 60 % of those diagnosed with mental illness or in substance abuse treatment
report physical, sexual or emotional abuse.

Don't dismiss the evidence of the experiences behind these statistics. This essay would
have more impact if I now told you stories, personal stories of the experiences of real
people. I can't. I would disturb myself, and you too much. Think of little girls and big
brothers, children and fathers, punishing mothers, think of rape, and incest, and
beatings. Think of a lifetime with those memories. Try not to look away.

In 1990 there were an estimated 10 million adults in the US diagnosed with serious
mental illness. (8) So then, statistically,
some six million of those were abused. Try not to look away.

If abuse is causal and if in the next generation we reduce abuse enough to divert even
10%, we might save 600 000 people from a mental illness diagnosis. Even if we find out
that abuse is not causal, merely correlative, we will have removed a variable, narrowed
the research areas, and will be doing a social good. For is sexual abuse any less wrong if
it does not lead to trauma and mental illness?

If abuse is not also a cause of chronic illness, we can learn what are the individual and
cultural strengths that lead to resilience and to recovery?

Perhaps there is a parallel pre-disposition to being abusers and using substances and
getting diagnosed with mental illness. What are the root causes of violence towards each
other.

Indeed, the trauma of the abuse may cause the brain changes that are reported to display
on brain imaging photos. But if that is the case we are only stopping symptoms. How much
better to stop traumatizing those brains. Overlooking trauma and its after-effects can
lead to wrong diagnosis and thus to wrong prescriptions for treatment.

Research has indeed found ventricle enlargements before medication treatment. They've
concluded this defect links to schizophrenia. (9)
I haven't seen that social histories were taken. I would like to know if it is trauma that
has caused the enlargements, trauma perhaps caused by sexual abuse.

Or perhaps trauma causes frontal brain damage, damage that can cause emotion to lose its
anchor in previous experience, leading, Brown speculates, to an absence of wisdom in the
management of daily behavior. (10)

Now, we medicalize this persistent social problem of person-against- person violence by
looking at the individual perpetrator and the individual victim. The focus on the
individual leaves unexamined the community and family factors. It's time for intervention
and prevention at the community level. In 2002, the theme for World Mental Health Day will
be connected to mental health and violence, and specific action strategies may emerge.

Now, by de-emphasizing upstream risks like abuse we assure a steady downstream flow of
problems and a concomitant increase in the size and costs of the behavioral health
industry.

"When coping with the social problems caused by a lack of cohesion and social
justice, there is a tendency to see new services as the answer, but in fact it is
essential that the main causes of problems be confronted at a policy level which affects
the well-being of the whole population." (11)

Proactive prevention is needed. Outrage is what's called for. Enough outrage to withdraw
the social permission for abuse. Janet Reno says: "Violence is not inevitable, nor an
abstract force against which we are powerless. We can end violence if we as individuals,
as communities and as a nation decide not to condone it and not to remain passive." (12)

Ignoring the upstream perpetrators while shaming the individual victim is off the mark The
shame belongs to society. Let us make not abusing each other our shared practice.